We, the householders of ______________, an isolated community comprised of __________householders, hereby agree to move
and request assistance under the Household Resettlement Act (April 15, 1965).

PART 2

Name

Place ofResettlement

ProposedDate of Move

LivingArrangements

No. inH. Hold

ChildrenSchool Age others

OCCUPATIONPresent Intended

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

number
number
(Use additional sheet if the space here is not sufficient)
This is to certify that _____ of _____ householders living at
________________ have signed this Petition and we are enclosing
SIGNED: ___________________________
completed forms on the communities to which householders intend to move
Local Committee Chairman

Dated this __________ day of ________month, the year 19__.
___________________________
Members